covid-19...mar 19, 2020 · covid19 provider telehealth letter 20pv1281727 (vw) 3/19/2020 . ......
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*This information is subject to change as the situation evolves. ‡ Self-funded plans that have opted out of coverage and qualified high-deductible health plan members may be subject to cost-sharing. The provider of care is ultimately responsible for providing accurate and compliant information on all submission of claims and/or billing information.
Copyright 2020 UPMC Health Plan, Inc. All rights reserved. COVID19 Provider Telehealth Letter 20PV1281727 (VW) 3/19/2020
Dear Valued Provider, As the COVID-19 situation evolves, UPMC Health Plan wants to provide our providers with continuous updates. Given efforts to contain the spread of COVID-19, there have been many questions surrounding telehealth and we want to share how UPMC Health Plan has broadened our approach for our telehealth services during this challenging time. Important information:
• UPMC Health Plan’s technical requirements and information on all covered telehealth services can be found in UPMC Heath Plan policy MP.148, which is available online through our Policies and Procedures Manual at upmchp.us/policiesandprocedures.
• UPMC Health Plan covers a brief (5-10 min) remote interaction, typically via telephone between a provider and their existing patient. This visit cannot be related to an Evaluation and Management (E/M) visit within the previous seven days or result in an E/M visit or appointment in the next 24 hours. This service is known as a “Virtual Check-In” and can be billed using code G2012.
• Providers should bill their current Place of Service as 02 for telehealth visits. • Behavioral health telehealth visits are covered as indicated in UPMC Health Plan Telehealth policy MP.148. • Effective immediately until June 15, patients can get medical attention quickly and safely at $0 copay for all
covered telehealth services. UPMC Health Plan will waive any deductibles,‡ copayments, or other cost-sharing for all in-network telehealth visits, including UPMC AnywhereCare. Patients who are not UPMC Health Plan members can still access UPMC AnywhereCare; they will be charged $59 for the visit.
• As previously communicated, effective immediately until June 15, UPMC Health Plan will cover COVID-19 diagnostic laboratory testing at no-cost as a preventive service for UPMC Health Plan members.
• As previously communicated, no member cost-share will apply to TESTING procedures only for all UPMC Health Plan products and providers if billed under CPT Code 87635 OR HCPCS Code U0002. These procedures do not require prior authorization.
• UPMC Health Plan is committed to complying with CMS and state requirements for telehealth services. Please check our websites listed below for daily updates.
Please keep up to date on the most recent information by visiting and consistently checking back for updates: • UPMC Health Plan provider announcements: upmchp.us/announcement-updates • UPMC Health Plan coronavirus website: www.upmchealthplan.com/covid-19 • UPMC Health Plan Policies and Procedures Manual: upmchp.us/policiesandprocedures • CDC Website: upmchp.us/cdc-covid-19
Thank you for your cooperation and continued participation with UPMC Health Plan. If you have any questions, please contact your physician account executive or Provider Services at 1-866-918-1595.
Sincerely, Kimberly Zynn Vice President, National Network Development and Strategic Expansion UPMC Health Plan
UPMC Health Plan
POLICY AND PROCEDURE MANUAL
POLICY NUMBER: MP.148
REVISION DATE: 03/20
EFFECTIVE DATE: 03/20
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Proprietary and Confidential Information of UPMC Health Plan TOP © 2020 UPMC All Rights Reserved
SUBJECT: Telehealth
INDEX TITLE: Medical Management
ORIGINAL DATE: July 2019
This policy applies to the following lines of business: (Check those that apply.)
COMMERCIAL CMS-MA DHS-MA ANCILLARY
HMO ( ) PA (X) Health Choices/PH (X) Dental ( )
PPO ( ) Ohio ( ) Health Choices/BH ( ) Vision ( )
Fully Insured ( ) All ( ) All ( ) COBRA ( )
Self Funded ( ) All ( )
Marketplace HMO ( ) HMO (X) CHIP
Marketplace PPO ( ) PPO (X) CHIP (X) WORKPARTNERS
Marketplace EPO ( ) DSNP (X) Commercial WC ( )
Indiv. Off Exchange ( ) Part D ( ) COMMUNITY
HEALTHCHOICES
WCTPA ( )
All (X) All ( )
Disability Svcs. ( )
CHC/MLTSS (X)
CDHP Life Solutions/Health Promo ( )
HSA (X) COMMUNITY CARE Life Solutions/EAP ( )
HRA X) Community Care/BH ( ) HCMS Group ( )
HIA (X) eBenefits Solutions ( )
FSA ( ) On Site Centers ( )
All () All ( )
Reference State Addendums for:
Delaware ( ) Ohio ( ) Maryland ( ) Virginia ( ) Wisconsin ( )
A. Medical Description/Background
B. Specific Indications
C. Limitations
D. Information Required for Review
E. Variations
F. Codes
I. POLICY
It is the policy of UPMC Insurance Services Division to provide payment for telehealth
services when medically necessary, clinically appropriate, and covered by the member’s
specific benefit plan.
II. DEFINITIONS
Critical Access Hospital (CAH) Optional Payment Method II: Under Section
1834(g)(2) of the Social Security Act, a Critical Access Hospital (CAH) may elect the
Optional Payment Method, better known as Method II Billing, for the payment of both
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facility services and professional services furnished to its outpatients by a physician or
practitioner who has reassigned their billing rights to the CAH.
CMS: Centers for Medicare and Medicaid Services, the Health and Human Services
agency responsible for Medicare and parts of Medicaid
Current Procedural Terminology (CPT - Healthcare Common Procedure Coding
System Level I): A set of standardized codes, descriptions, and guidelines intended to
describe procedures and services performed by physicians and other health care providers
during a medical encounter. Each procedure or service is identified with a five-digit
code.
Department of Human Services (DHS): DHS offices administer services that provide
care and support to Pennsylvania's most vulnerable individuals and families
Healthcare Common Procedure Coding System (HCPCS Level II Codes): These
represent national codes that are used to report supplies and equipment, as well as select
services provided on an outpatient basis. HCPCS codes are published by CMS and
updated quarterly. HCPCS codes consist of one alpha character (A-V) followed by four
digits. HCPCS level II codes describe durable medical equipment, medications, provider
services, temporary Medicare codes, temporary national codes and other disparate items
and services as ambulance services.
International Classification of Disease, Tenth Revision (ICD-10-CM/PCS): A listing
of diagnoses and identifying codes used by physicians for reporting diagnoses of UPMC
Insurance Services Division enrollees. The coding and terminology provide a uniform
language that can accurately designate primary and secondary diagnoses and provide for
reliable, consistent communication on claim forms.
MC400: A transactional system for processing membership, billing, medical claims and
payment data.
Modifier: These are found in the form of two characters, either numbers, letters or a
combination of each and are intended to append specific information to a certain
procedure or service. Modifiers are a mechanism to indicate that a service or procedure
has been “modified” by some circumstance, but the service itself is still described by the
CPT or Level II HCPCS code definition.
• Modifier GT: Via interactive audio and video telecommunication systems. Modifier
used to indicate telehealth services.
• Modifier G0: Telehealth services for diagnosis, evaluation, or treatment, of
symptoms of an acute stroke.
• Modifier GQ: Via asynchronous telecommunications system. Modifier used to
indicate telehealth services.
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• Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time
Interactive Audio and Video Telecommunications System. Modifier 95 may only be
appended to the services listed in the coding section of this policy. The coding
section contains the list of CPT codes for services that are typically performed face-
to-face but may be rendered via real-time (synchronous) interactive audio and video
telecommunications system.
Place of Service code: A two-digit code placed on health care professional claims to
indicate the setting in which a service was provided. The Centers for Medicare &
Medicaid Services (CMS) maintain POS codes used throughout the health care industry.
• POS Code 02: The location where health services and health related services are
provided or received, through telecommunication technology.
Telehealth: A broad range of technologies and services to provide patient care and
improve the healthcare delivery system.
• Asynchronous communication: A store and forward method that transmits medical
data to a physician or practitioner for later review and do not require real-time
communication between the sender and receiver of the information.
• Synchronous conversation: A real-time communication (virtual visit) using
interactive audio and visual equipment, such as video conferences between a patient
and specialist.
• Remote patient monitoring: This allows a provider to continue to track healthcare
data for a patient released to his or her home or a care facility.
Telemedicine: A delivery of health care services over a distance using
telecommunications technology. For the purposes of this policy, telehealth and
telemedicine will be used interchangeably.
III. PURPOSE
The purpose of this policy is to:
• Ensure clinical appropriateness with respect to the delivery and reimbursement of
all of all telemedicine/telehealth services;
• Provide clear billing protocols;
• Stipulate minimum requirements for technologies used to provide telehealth
services; and
• Support all audit requirements related to telehealth services.
IV. SCOPE
This policy applies to various UPMC Insurance Services Division departments as
indicated by the Benefit and Reimbursement Committee. These include but are not
limited to Medical Management, Benefit Configuration, and Claims Departments.
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V. PROCEDURE
A. Medical Description
Telehealth is the use of electronic and communication technologies to provide and
support health care when distance separates the patient from the provider. It utilizes
interactive telecommunications technology (e.g., audio and video equipment) to permit
either two-way interactive communication between the patient and physician or allow the
physician to review the medical case without the patient being present in order to confirm
a diagnosis and/or establish a treatment plan. Telehealth can be a useful alternative to
traditional office visits when barriers to access (i.e., physical distance between patient
and physician, non-ambulatory or isolated patient, time) exist. Telehealth enables
providers to extend their reach and improve their efficiency and effectiveness while still
maintaining high quality care and attention to patient safety.
Telehealth is practiced either in real-time or as store-and-forward. Real-time
telemedicine requires the simultaneous attendance of provider and patient, or of multiple
providers to a communications link that allows real-time interaction. Store-and-forward
telemedicine involves the acquisition and transmission of medical data from the patient to
a medical provider for review and later assessment - it does not require the simultaneous
presence of both parties or a real-time communication link.
For the purposes of this policy, telehealth and telemedicine will be used interchangeably.
B. Specific Indications
• There are many potential clinical areas and indications where telehealth can be
used.
o It can be used in the inpatient hospital, nursing facility, office and/or other
outpatient care settings.
• When care is delivered via telehealth it should be clinically appropriate while
maintaining patient confidentiality and conducted in a manner consistent with
professionally recognized standards of health care. Clinical appropriateness
should be clear from the medical record to indicate appropriateness.
• Telehealth should only be used by appropriate licensed health care and behavioral
health providers for services that would normally be covered by each line of
business under UPMC (Commercial, UPMC for Life [Medicare], UPMC for You
[Medical Assistance], UPMC for Kids [CHIP]) in a hospital/office setting.
When using telehealth technologies and systems to render services, providers must
consider security, patient confidentiality, and privacy. A HIPAA-compliant, secured
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electronic channel is required to be used for the purpose of telemedicine encounters. The
electronic channel must include and support all of the following:
1. Access controls;
2. Encryption and decryption;
3. Audit controls;
4. Transmission security;
5. Third party storage considerations including a Business Associate Agreement;
6. HIPAA technical safeguards; and
7. Payment Card Industry Data Security Standard (PCI-DSS) compliant.
Note: Details of technology requirements can be found in the Limitations section.
C. Limitations
Limitations to telehealth services include all of the following:
1. The service must be within a practitioner’s scope of specialty practice and state
law.
2. The practitioner must be licensed to provide the service under the laws of the state
where the patient is located.
3. Telehealth must be conducted by a provider from a private setting that is
appropriate for clinical services.
Technology Requirements
Security and confidentiality related to all PHI and service delivery using telehealth
technologies must be strictly safeguarded in accordance with state and federal laws
including HHS security requirements (https://www.hhs.gov/hipaa/for-
professionals/security/index.html) and the below specifications.
1. Access Control
• All telemedicine practices (e.g. audio, video, messaging, chat, etc.) must be
conducted on a secure, HIPAA compliant technology platform.
• Access control - Implement technical policies and procedures for electronic
information systems that maintain electronic protected health information to
allow access only to those persons or software programs that have been
granted access rights as specified in § 164.308(a)(4).
• Unique user identification - Assign a unique name and/or number for
identifying and tracking user identity.
• Person or entity authentication - Implement procedures to verify that a person
or entity seeking access to electronic protected health information is the one
claimed.
• Implement electronic procedures that terminate an electronic session after a
predetermined time of inactivity.
2. Data at Rest
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• Encryption and decryption. Implement a mechanism to encrypt and decrypt
electronic protected health information. PHI information must be encrypted at
rest with a minimum 256-bit encryption.
• Audit controls. Implement hardware, software, and/or procedural mechanisms
that record and examine activity in information systems that contain or use
electronic protected health information.
• Integrity. Implement policies and procedures to protect electronic protected
health information from improper alteration or destruction.
3. Data in Motion
• Transmission security - Implement technical security measures to guard
against unauthorized access to electronic protected health information that is
being transmitted over an electronic communications network.
• Implement security measures to ensure that electronically transmitted
electronic protected health information is not improperly modified without
detection until disposed of.
• Implement a mechanism to encrypt electronic protected health information
whenever deemed appropriate.
• HIPAA guidelines require that any software transmitting protected personal
health information meet a 128-bit level of encryption over Transport Layer
Security protocol (TLS 1.2), at a minimum. Traffic encrypted with FIPS 140-
2 compliant 256-bit Advanced Encryption Standard is preferred.
• Valid encryption processes for data in motion are those that comply with the
requirements of Federal Information Processing Standards (FIPS) 140–2.
4. Organizational Requirements
• If data is stored by a third party, the covered entity is required to have a
Business Associate Agreement (BAA) with the party storing the data. This
BAA must include methods used by the third party to ensure the protection of
the data including encryption methods, documentation on their security
practices, and emergency protocols and provisions for regular auditing of the
data’s security.
• Business associate contracts - The contract must provide that the business
associate will comply with HIPAA, appropriate HHS standards, and the
requirements of this policy.
• Comply with the applicable requirements of HIPAA technical safeguards
requirements.
• In accordance with HIPAA regulations, ensure that any subcontractors that
create, receive, maintain, or transmit electronic protected health information
on behalf of the business associate agree to comply with the applicable
requirements of HIPAA by entering into a contract or other arrangement that
complies with this HIPAA technical safeguards.
• Report to the covered entity any security incident of which it becomes aware,
including breaches of unsecured protected health information as required.
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5. Non-compliant app:
• Although digital applications like Skype & FaceTime meet or exceed
requirements for encryption, that doesn't automatically mean the software is
HIPAA compliant.
• In order to comply with the HIPAA Omnibus Rule, Skype/FaceTime would
need to enter into a BAA with any health provider concerned about HIPAA
compliant video conferencing. Since Skype/FaceTime are not designed
specifically for healthcare purposes, they do not sign BAAs. Skype/FaceTime
do not meet criteria for BAA exemption, either as the software transmits more
than protected health information.
• For the above reasons, Skype/FaceTime and alike application are not HIPAA
compliant and will be considered not clinically appropriate.
D. Information Required for Review
Adequate documentation in the patient’s medical record must include date and duration
of the health care service(s) provided, the technology used, and sufficient detail to
establish clinical appropriateness for the use of telehealth services. This information
must be readily available upon request.
E. Variations
Commercial and UPMC for Kids (CHIP):
UPMC Health Plan Commercial telehealth coding guidelines are as follows:
• Place of service (POS) 02 is the recognized POS code for telehealth billing.
Utilization of POS 02 is the preferred method of coding for telehealth services.
• Modifier 95 for CPT Telemedicine Service Codes is also an accepted telehealth
billing method in addition to POS 02.
•
UPMC for Life (Medicare):
UPMC Health Plan complies with all Medicare National Coverage Determinations
(NCDs) and applicable Local Coverage Determinations (LCDs) for all items, services
and/or procedures that are covered benefits under Medicare. If the description of
coverage criteria in this policy conflicts with any NCD or relevant LCD, the NCD or
relevant LCD controls regardless of the version of the NCD or LCD listed in the
Reference section of this policy.
• UPMC for Life mirrors CMS’s decision to eliminate geographic restrictions.
UPMC for You and UPMC Community HealthChoices (Medical Assistance):
UPMC Health Plan Medicaid telehealth coding guidelines are as follows:
• UPMC Health Plan Medicaid products will follow Pennsylvania DHS billing and
coding guidelines. These products will also follow stated DHS Fee Schedule.
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• UPMC Health Plan also recognizes and accepts additional codes for Medicaid
products.
• Certain telehealth codes are not on the Medical Assistance fee schedule. These
procedures may only be requested as a Program Exception under the Program
Exception process.
F. Codes
The following codes for treatments and procedures applicable to this policy are included
below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or
device code(s) does not constitute or imply coverage or reimbursement. Please refer to
the specific contract benefits in effect at the time of service to determine coverage or non-
coverage of these services as it applies to an individual.
**In order to track and pay appropriately, the Health Plan requires POS to be
utilized with CPT/HCPCS codes for all Telehealth encounters.
Place of Service (POS) and Modifiers
POS Description
02 The location where health services and health related services are provided
or received, through telecommunication technology
Modifiers Description
95 Synchronous telemedicine service rendered via a real-time interactive
audio and video telecommunications system
G0 Telehealth services for diagnosis, evaluation, or treatment, of symptoms of
an acute stroke
GQ Via asynchronous telecommunications system
GT Via interactive audio and video telecommunication systems
• CHIP Coding
CPT Codes: Description
90785 Interactive complexity (List separately in addition to the code for
primary procedure)
90791 Psychiatric diagnostic evaluation
90792 Psychiatric diagnostic evaluation with medical services
90832 Psychotherapy, 30 minutes with patient
90833 Psychotherapy, 30 minutes with patient when performed with an
evaluation and management service (List separately in addition to
the code for primary procedure)
90834 Psychotherapy, 45 minutes with patient
90836 Psychotherapy, 45 minutes with patient when performed with an
evaluation and management service (List separately in addition to
the code for primary procedure)
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90837 Psychotherapy, 60 minutes with patient
90838 Psychotherapy, 60 minutes with patient when performed with an
evaluation and management service (List separately in addition to
the code for primary procedure)
90839 Psychotherapy for crisis; first 60 minutes
90840 Psychotherapy for crisis; each additional 30 minutes (List
separately in addition to code for primary service)
90845 Psychoanalysis
90846 Family psychotherapy (without the patient present), 50 minutes
90847 Family psychotherapy (conjoint psychotherapy)(with patient
present), 50 minutes
90863 Pharmacologic management, including prescription and review of
medication, when performed with psychotherapy services (List
separately in addition to the code for primary procedure)
90951 End-stage renal disease (ESRD) related services monthly, for
patients younger than 2 years of age to include monitoring for the
adequacy of nutrition, assessment of growth and development, and
counseling of parents; with 4 or more face-to-face visits by a
physician or other qualified health care professional per month
90952 End-stage renal disease (ESRD) related services monthly, for
patients younger than 2 years of age to include monitoring for the
adequacy of nutrition, assessment of growth and development, and
counseling of parents; with 2-3 face-to-face visits by a physician or
other qualified health care professional per month
90953 End-stage renal disease (ESRD) related services monthly, for
patients younger than 2 years of age to include monitoring for the
adequacy of nutrition, assessment of growth and development, and
counseling of parents; with 1 face-to-face visit by a physician or
other qualified health care professional per month
90954 End-stage renal disease (ESRD) related services monthly, for
patients 2-11 years of age to include monitoring for the adequacy
of nutrition, assessment of growth and development, and
counseling of parents; with 4 or more face-to-face visits by a
physician or other qualified health care professional per month
90955 End-stage renal disease (ESRD) related services monthly, for
patients 2-11 years of age to include monitoring for the adequacy
of nutrition, assessment of growth and development, and
counseling of parents; with 2-3 face-to-face visits by a physician or
other qualified health care professional per month
90956 End-stage renal disease (ESRD) related services monthly, for
patients 2-11 years of age to include monitoring for the adequacy
of nutrition, assessment of growth and development, and
counseling of parents; with 1 face-to-face visit by a physician or
other qualified health care professional per month
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90957 End-stage renal disease (ESRD) related services monthly, for
patients 12-19 years of age to include monitoring for the adequacy
of nutrition, assessment of growth and development, and
counseling of parents; with 4 or more face-to-face visits by a
physician or other qualified health care professional per month
90958 End-stage renal disease (ESRD) related services monthly, for
patients 12-19 years of age to include monitoring for the adequacy
of nutrition, assessment of growth and development, and
counseling of parents; with 2-3 face-to-face visits by a physician or
other qualified health care professional per month
90959 End-stage renal disease (ESRD) related services monthly, for
patients 12-19 years of age to include monitoring for the adequacy
of nutrition, assessment of growth and development, and
counseling of parents; with 1 face-to-face visit by a physician or
other qualified health care professional per month
90960 End-stage renal disease (ESRD) related services monthly, for
patients 20 years of age and older; with 4 or more face-to-face
visits by a physician or other qualified health care professional per
month
90961 End-stage renal disease (ESRD) related services monthly, for
patients 20 years of age and older; with 2-3 face-to-face visits by a
physician or other qualified health care professional per month
90962 End-stage renal disease (ESRD) related services monthly, for
patients 20 years of age and older; with 1 face-to-face visit by a
physician or other qualified health care professional per month
90963 End-stage renal disease (ESRD) related services for home dialysis
per full month, for patients younger than 2 years of age to include
monitoring for the adequacy of nutrition, assessment of growth and
development, and counseling of parents
90964 End-stage renal disease (ESRD) related services for home dialysis
per full month, for patients 2-11 years of age to include monitoring
for the adequacy of nutrition, assessment of growth and
development, and counseling of parents
90965 End-stage renal disease (ESRD) related services for home dialysis
per full month, for patients 12-19 years of age to include
monitoring for the adequacy of nutrition, assessment of growth and
development, and counseling of parents
90966 End-stage renal disease (ESRD) related services for home dialysis
per full month, for patients 20 years of age and older
90967 End-stage renal disease (ESRD) related services for dialysis less
than a full month of service, per day; for patients younger than 2
years of age
90968 End-stage renal disease (ESRD) related services for dialysis less
than a full month of service, per day; for patients 2-11 years of age
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90969 End-stage renal disease (ESRD) related services for dialysis less
than a full month of service, per day; for patients 12-19 years of
age
90970 End-stage renal disease (ESRD) related services for dialysis less
than a full month of service, per day; for patients 20 years of age
and older
92227 Remote imaging for detection of retinal disease (e.g., retinopathy
in a patient with diabetes) with analysis and report under physician
supervision, unilateral or bilateral
92228 Remote imaging for monitoring and management of active retinal
disease (e.g., diabetic retinopathy) with physician review,
interpretation and report, unilateral or bilateral
93228 External mobile cardiovascular telemetry with
electrocardiographic recording, concurrent computerized real time
data analysis and greater than 24 hours of accessible ECG data
storage (retrievable with query) with ECG triggered and patient
selected events transmitter to a remote attended surveillance center
for up to 30 days; review and interpretation with report by a
physician or other qualified health care professional
93229 External mobile cardiovascular telemetry with
electrocardiographic recording, concurrent computerized real time
data analysis and greater than 24 hours of accessible ECG data
storage (retrievable with query) with ECG triggered and patient
selected events transmitter to a remote attended surveillance center
for up to 30 days; technical support for connection and patient
instructions for use, attended surveillance, analysis and
transmission of daily and emergent data reports as prescribed by a
physician or other qualified health care professional
93268 External patient and, when performed, auto activated
electrocardiographic rhythm derived event recording with
symptom-related memory loop with remote download capability
up to 30 days, 24-hour attended monitoring; includes transmission,
review and interpretation by a physician or other qualified health
care professional
93270 External patient and, when performed, auto activated
electrocardiographic rhythm derived event recording with
symptom-related memory loop with remote download capability
up to 30 days, 24-hour attended monitoring; recording (includes
connection, recording, and disconnection)
93271 External patient and, when performed, auto activated
electrocardiographic rhythm derived event recording with
symptom-related memory loop with remote download capability
up to 30 days, 24-hour attended monitoring; transmission and
analysis
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93272 External patient and, when performed, auto activated
electrocardiographic rhythm derived event recording with
symptom-related memory loop with remote download capability
up to 30 days, 24-hour attended monitoring; review and
interpretation by a physician or other qualified health care
professional
93298 Interrogation device evaluation(s), (remote) up to 30 days;
subcutaneous cardiac rhythm monitor system, including analysis of
recorded heart rhythm data, analysis, review(s) and report(s) by a
physician or other qualified health care professional
96040 Medical genetics and genetic counseling services, each 30 minutes
face-to-face with patient/family
96116 Neurobehavioral status examination (clinical assessment of
thinking, reasoning and judgement, [e.g., acquired knowledge,
attention, language, memory, planning and problem solving, and
visual spatial abilities]), by physician or other qualified health care
professional, both face-to-face time with the patient and time
interpreting test results and preparing the report; first hour
96121 Neurobehavioral status examination (clinical assessment of
thinking, reasoning and judgement, [e.g., acquired knowledge,
attention, language, memory, planning and problem solving, and
visual spatial abilities]), by physician or other qualified health care
professional, both face-to-face time with the patient and time
interpreting test results and preparing the report; each additional
hour (List separately in addition to code for primary procedure)
96156 Health behavior assessment, or re-assessment (i.e. health-focused
clinical interview, behavioral observations, clinical decision
making)
96158 Health behavior intervention, individual, face-to-face; initial 30
minutes
96159 Health behavior intervention, individual, face-to-face; each
additional 15 minutes (List separately in addition to code for
primary service)
96160 Administration of patient-focused health risk assessment
instrument (e.g., health hazard appraisal) with scoring and
documentation, per standardized instrument
96161 Administration of caregiver-focused health risk assessment
instrument (e.g., depression inventory) for the benefit of the
patient, with scoring and documentation, per standardized
instrument
96164 Health behavior intervention, group (2 or more patients), face-to-
face; initial 30 minutes
96165 Health behavior intervention, group (2 or more patients), face-to-
face; each additional 15 minutes (List separately in addition to
code for primary service)
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96167 Health behavior intervention, family (with the patient present),
face-to-face; initial 30 minutes
96168 Health behavior intervention, family (with the patient present),
face-to-face; each additional 15 minutes (List separately in
addition to code for primary service)
96170 Health behavior intervention, family (without the patient present),
face-to-face; initial 30 minutes
96171 Health behavior intervention, family (without the patient present),
face-to-face; each additional 15 minutes (List separately in
addition to code for primary service)
97802 Medical nutrition therapy; initial assessment and intervention,
individual, face-to-face with the patient, each 15 minutes
97803 Medical nutrition therapy; re-assessment and intervention,
individual, face-to-face with the patient, each 15 minutes
97804 Medical nutrition therapy; group (2 or more individual(s)), each 30
minutes
98960 Education and training for patient self-management by a qualified,
nonphysician health care professional using a standardized
curriculum, face-to-face with the patient (could include
caregiver/family) each 30 minutes; individual patient
98961 Education and training for patient self-management by a qualified,
nonphysician health care professional using a standardized
curriculum, face-to-face with the patient (could include
caregiver/family) each 30 minutes; 2-4 patients
98962 Education and training for patient self-management by a qualified,
nonphysician health care professional using a standardized
curriculum, face-to-face with the patient (could include
caregiver/family) each 30 minutes; 5-8 patients
99201 Office or other outpatient visit for the evaluation and management
of a new patient, which requires these 3 key components: a
problem focused history; a problem focused examination;
straightforward medical decision making
99202 Office or other outpatient visit for the evaluation and management
of a new patient, which requires these 3 key components: an
expanded problem focused history; an expanded problem focused
examination; straightforward medical decision making
99203 Office or other outpatient visit for the evaluation and management
of a new patient, which requires these 3 key components: a
detailed history; a detailed examination; medical decision making
of low complexity
99204 Office or other outpatient visit for the evaluation and management
of a new patient, which requires these 3 key components: a
comprehensive history; a comprehensive examination; medical
decision making of moderate complexity
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99205 Office or other outpatient visit for the evaluation and management
of a new patient, which requires these 3 key components: a
comprehensive history; a comprehensive examination; medical
decision making of high complexity
99211 Office or other outpatient visit for the evaluation and management
of an established patient, that may not require the presence of a
physician or other qualified health care professional. Usually, the
presenting problem(s) are minimal. Typically, 5 minutes are spent
performing or supervising these services.
99212 Office or other outpatient visit for the evaluation and management
of an established patient, which requires at least 2 of these 3
components: a problem focused history; a problem focused
examination; straightforward medical decision making
99213 Office or other outpatient visit for the evaluation and management
of an established patient, which requires at least 2 of these 3
components: an expanded problem focused history; an expanded
problem focused examination; medical decision making of low
complexity
99214 Office or other outpatient visit for the evaluation and management
of an established patient, which requires at least 2 of these 3
components: a detailed history; a detailed examination; medical
decision making of moderate complexity
99215 Office or other outpatient visit for the evaluation and management
of an established patient, which requires at least 2 of these 3
components: a comprehensive history; a comprehensive
examination; medical decision making of high complexity
99231 Subsequent hospital care, per day, for the evaluation and
management of a patient, which requires at least 2 of these 3
components: a problem focused interval history; a problem focused
examination; medical decision making that is straightforward or of
low complexity
99232 Subsequent hospital care, per day, for the evaluation and
management of a patient, which requires at least 2 of these 3
components: an expanded problem focused interval history; an
expanded problem focused examination; medical decision making
of moderate complexity
99233 Subsequent hospital care, per day, for the evaluation and
management of a patient, which requires at least 2 of these 3
components: a detailed interval history; a detailed examination;
medical decision making of high complexity
99241 Office consultation for a new or established patient, which requires
these 3 key components: a problem focused history; a problem
focused examination; and straightforward medical decision making
99242 Office consultation for a new or established patient, which requires
these 3 key components: an expanded problem focused history; an
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expanded problem focused examination; and straightforward
medical decision making
99243 Office consultation for a new or established patient, which requires
these 3 key components: a detailed history; a detailed examination;
and medical decision making of low complexity
99244 Office consultation for a new or established patient, which requires
these 3 key components: a comprehensive history; a
comprehensive examination; and medical decision making of
moderate complexity
99245 Office consultation for a new or established patient, which requires
these 3 key components: a comprehensive history; a
comprehensive examination; and medical decision making of high
complexity
99251 Inpatient consultation for a new or established patient, which
requires these 3 key components: a problem focused history; a
problem focused examination; and straightforward medical
decision making
99252 Inpatient consultation for a new or established patient, which
requires these 3 key components: an expanded problem focused
history; an expanded problem focused examination; and
straightforward medical decision making
99253 Inpatient consultation for a new or established patient, which
requires these 3 key components: a detailed history; a detailed
examination; and medical decision making of low complexity
99254 Inpatient consultation for a new or established patient, which
requires these 3 key components: a comprehensive history; a
comprehensive examination; and medical decision making of
moderate complexity
99255 Inpatient consultation for a new or established patient, which
requires these 3 key components: a comprehensive history; a
comprehensive examination; and medical decision making of high
complexity
99307 Subsequent nursing facility care, per day, for the evaluation and
management of a patient, which requires at least 2 of these 3 key
components: a problem focused interval history; a problem focused
examination; straightforward medical decision making
99308 Subsequent nursing facility care, per day, for the evaluation and
management of a patient, which requires at least 2 of these 3 key
components: an expanded problem focused interval history; an
expanded problem focused examination; medical decision making
of low complexity
99309 Subsequent nursing facility care, per day, for the evaluation and
management of a patient, which requires at least 2 of these 3 key
components: a detailed interval history; a detailed examination;
medical decision making of moderate complexity
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99310 Subsequent nursing facility care, per day, for the evaluation and
management of a patient, which requires at least 2 of these 3 key
components: a comprehensive interval history; a comprehensive
examination; medical decision making of high complexity
99354 Prolonged evaluation and management or psychotherapy service(s)
(beyond the typical service time of the primary procedure) in the
office or other outpatient setting requiring direct patient contact
beyond the usual service; first hour (List separately in addition to
code for office or other outpatient Evaluation and Management or
psychotherapy service)
99355 Prolonged evaluation and management or psychotherapy service(s)
(beyond the typical service time of the primary procedure) in the
office or other outpatient setting requiring direct patient contact
beyond the usual service; each additional 30 minutes (List
separately in addition to code for prolonged service)
99356 Prolonged service in the inpatient or observation setting, requiring
unit/floor time beyond the usual service; first hour (List separately
in addition to code for inpatient Evaluation and Management
service)
99357 Prolonged service in the inpatient or observation setting, requiring
unit/floor time beyond the usual service; each additional 30
minutes (List separately in addition to code for prolonged service)
99406 Smoking and tobacco use cessation counseling visit; intermediate,
greater than 3 minutes up to 10 minutes
99407 Smoking and tobacco use cessation counseling visit; intensive,
greater than 10 minutes
99408 Alcohol and/or substance (other than tobacco) abuse structured
screening (e.g., AUDIT, DAST), and brief intervention (SBI)
services; 15 to 30 minutes
99409 Alcohol and/or substance (other than tobacco) abuse structured
screening (e.g., AUDIT, DAST), and brief intervention (SBI)
services; greater than 30 minutes
99421 Online digital evaluation and management service, for an
established patient, for up to 7 days, cumulative time during the 7
days; 5-10 minutes
99422 Online digital evaluation and management service, for an
established patient, for up to 7 days, cumulative time during the 7
days; 11-20 minutes
99423 Online digital evaluation and management service, for an
established patient, for up to 7 days, cumulative time during the 7
days; 21 or more minutes
99446 Interprofessional telephone/Internet/electronic health record
assessment and management service provided by a consultative
physician, including a verbal and written report to the patient’s
treating/requesting physician or other qualified health care
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professional; 5-10 minutes of medical consultative discussion and
review
99447 Interprofessional telephone/Internet/electronic health record
assessment and management service provided by a consultative
physician, including a verbal and written report to the patient’s
treating/requesting physician or other qualified health care
professional; 11-20 minutes of medical consultative discussion and
review
99448 Interprofessional telephone/Internet/electronic health record
assessment and management service provided by a consultative
physician, including a verbal and written report to the patient’s
treating/requesting physician or other qualified health care
professional; 21-30 minutes of medical consultative discussion and
review
99449 Interprofessional telephone/Internet/electronic health record
assessment and management service provided by a consultative
physician, including a verbal and written report to the patient’s
treating/requesting physician or other qualified health care
professional; 31 minutes or more of medical consultative
discussion and review
99451 Interprofessional telephone/Internet/electronic health record
assessment and management service provided by a consultative
physician, including a written report to the patient’s
treating/requesting physician or other qualified health care
professional, 5 minutes or more of medical consultative time
99452 Interprofessional telephone/Internet/electronic health record
referral service(s) provided by a treating/requesting physician or
other qualified health care professional, 30 minutes
99453 Remote monitoring of physiologic parameter(s) (e.g., weight blood
pressure, pulse oximetry, respiratory flow rate), initial; set-up and
patient education on use of equipment
99454 Remote monitoring of physiologic parameter(s) (e.g., weight blood
pressure, pulse oximetry, respiratory flow rate), initial; device(s)
supply with daily recording(s) or programmed alert(s)
transmission, each 30 days
99457 Remote physiologic monitoring treatment management services,
clinical staff/physician/ other qualified health care professional
time in a calendar month requiring interactive communication with
the patient/caregiver during the month; first 20 minutes
99458 Remote physiologic monitoring treatment management services,
clinical staff/physician/ other qualified health care professional
time in a calendar month requiring interactive communication with
the patient/caregiver during the month; each additional 20 minutes
(List separately in addition to code for primary procedure)
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99473 Self-measured blood pressure using a device validated for clinical
accuracy; patient education/training and device calibration
99474 Self-measured blood pressure using a device validated for clinical
accuracy; separate self-measurements of two readings one minute
apart, twice daily over a 30-day period (minimum of 12 readings),
collection of data reported by the patient and/or caregiver to the
physician or other qualified health care professional, with report of
average systolic and diastolic pressures and subsequent
communication of a treatment plan to the patient
99495 Transitional Care Management Services with the following require
elements: Communication (direct contact, telephone, electronic)
with the patient and/or caregiver within 2 business days of
discharge; medical decision making of at least moderate
complexity during the service period; face-to-face visit, within 14
calendar days of discharge
99496 Transitional Care Management Services with the following require
elements: communication (direct contact, telephone, electronic)
with the patient and/or caregiver within 2 business days of
discharge; medical decision making of high complexity during the
service period; face-to-face visit, with 7 calendar days of discharge
99497 Advance care planning including the explanation and discussion of
advance directives such as standard forms (with completion of
such forms, when performed), by the physician or other qualified
health care professional; first 30 minutes, face-to-face with the
patient, family member(s), and/or surrogate
99498 Advance care planning including the explanation and discussion of
advance directives such as standard forms (with completion of
such forms, when performed), by the physician or other qualified
health care professional; each additional 30 minutes (List
separately in addition to code for primary procedure)
99499 Unlisted evaluation and management service
CHIP Coding
HCPCS Code: Description
G0108 Diabetes outpatient self-management training services, individual,
per 30 minutes
G0109 Diabetes outpatient self-management training services, group
session (2 or more), per 30 minutes
G0270 Medical nutrition therapy; reassessment and subsequent
intervention(s) following second referral in same year for change
in diagnosis, medical condition or treatment regiment (including
additional hours needed for renal disease), individual, face-to-face
with the patient, each 15 minutes
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G0296 Counseling visit to discuss need for lung cancer screening using
low dose CT scan (LDCT) (service is for eligibility determination
and shared decision making)
G0396 Alcohol and/or substance (other than tobacco) abuse structured
assessment (e.g., AUDIT, DAST), and brief intervention 15 to 30
minutes
G0397 Alcohol and/or substance (other than tobacco) abuse structured
assessment (e.g., AUDIT, DAST), and intervention, greater than
30 minutes
G0406 Follow-up inpatient consultation, limited, physicians typically
spend 15 minutes communicating with the patient via telehealth
G0407 Follow-up inpatient consultation, intermediate, physicians
typically spend 25 minutes communicating with the patient via
telehealth
G0408 Follow-up inpatient consultation, complex, physicians typically
spend 35 minutes communicating with the patient via telehealth
G0420 Face-to-face educational services related to the care of chronic
kidney disease; individual, per session, per one hour
G0421 Face-to-face educational services related to the care of chronic
kidney disease; group, per session, per one hour
G0425 Telehealth consultation, emergency department or initial inpatient,
typically 30 minutes communicating with the patient via telehealth
G0426 Telehealth consultation, emergency department or initial inpatient,
typically 50 minutes communicating with the patient via telehealth
G0427 Telehealth consultation, emergency department or initial inpatient,
typically 70 minutes or more communicating with the patient via
telehealth
G0438 Annual wellness visit; includes a personalized prevention plan of
service (PPS), initial visit
G0439 Annual wellness visit, includes a personalized prevention plan of
service (PPS), subsequent visit
G0442 Annual alcohol misuse screening, 15 minutes
G0443 Brief face-to-face behavioral counseling for alcohol misuse, 15
minutes
G0444 Annual depression screening, 15 minutes
G0445 Semiannual high intensity behavioral counseling to prevent STIs,
individual, face-to-face, includes education skills training &
guidance on how to change sexual behavior
G0446 Annual, face-to-face intensive behavioral therapy for
cardiovascular disease, individual, 15 minutes
G0447 Face-to-face behavioral counseling for obesity, 15 minutes
G0459 Inpatient telehealth pharmacologic management, including
prescription, use, and review of medication with no more than
minimal medical psychotherapy
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G0506 Comprehensive assessment of and care planning for patients
requiring chronic care management services (list separately in
addition to primary monthly care management service)
G0508 Telehealth consultation, critical care, initial, physicians typically
spend 60 minutes communicating with the patient and providers
via telehealth
G0509 Telehealth consultation, critical care, subsequent, physicians
typically spend 50 minutes communicating with the patient and
providers via telehealth
G0513 Prolonged preventive service(s)(beyond the typical service time of
the primary procedure), in the office or other outpatient setting
requiring direct patient contact beyond the usual service; first 30
minutes (list separately in addition to code for preventive service)
G0514 Prolonged preventive service(s)(beyond the typical service time of
the primary procedure), in the office or other outpatient setting
requiring direct patient contact beyond the usual service; each
additional 30 minutes (list separately in addition to code G0513 for
additional 30 minutes of preventative service)
G2010 Remote evaluation of recorded video and/or images submitted by
an established patient (e.g., store and forward), including
interpretation with follow-up with the patient with 24 business
hours, not originating from a related E/M service provided within
the previous 7 days nor leading to an E/M service or procedure
within the next 24 hours or soonest available appointment
G2011 Alcohol and/or substance (other than tobacco) abuse structured
assessment (e.g., audit, DAST), and brief intervention, 5-14
minutes
G2012 Brief communication technology-based service, e.g., virtual check-
in, by a physician or other qualified health care professional who
can report evaluation and management services, provided to an
established patient, not originating from a related E/M service
provided within the previous 7 days nor leading to an E/M service
or procedure within the next 24 hours or soonest available
appointment; 5-10 minutes of medical discussion
G2061 Qualified nonphysician health care professional online assessment,
for an established patient, for up to 7 days, cumulative time during
the 7 days; 5-10 minutes
G2062 Qualified nonphysician health care professional online assessment
service, for an established patient, for up to 7 days, cumulative
time during the 7 days; 11-20 minutes
G2063 Qualified nonphysician qualified health care professional
assessment service, for an established patient, for up to 7 days,
cumulative time during the 7 days; 21 or more minutes
G2086 Office-based treatment for opioid use disorder, including
development of the treatment plan, care coordination, individual
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therapy and group therapy and counseling; at least 70 minutes in
the first calendar month
G2087 Office-based treatment for opioid use disorder, including care
coordination, individual therapy and group therapy and counseling;
at least 60 minutes in a subsequent calendar month
G2088 Office-based treatment for opioid use disorder, including care
coordination, individual therapy and group therapy and counseling;
each additional 30 minutes beyond the first 120 minutes (list
separately in addition to code for primary procedure)
Q3014 Telehealth originating site facility fee
T1014 Telehealth transmission, per minute, professional services bill
separately
Commercial Coding
CPT Code: Description
90785 Interactive complexity (List separately in addition to the code for
primary procedure)
90791 Psychiatric diagnostic evaluation
90792 Psychiatric diagnostic evaluation with medical services
90832 Psychotherapy, 30 minutes with patient
90833 Psychotherapy, 30 minutes with patient when performed with an
evaluation and management service (List separately in addition to
the code for primary procedure)
90834 Psychotherapy, 45 minutes with patient
90836 Psychotherapy, 45 minutes with patient when performed with an
evaluation and management service (List separately in addition to
the code for primary procedure)
90837 Psychotherapy, 60 minutes with patient
90838 Psychotherapy, 60 minutes with patient when performed with an
evaluation and management service (List separately in addition to
the code for primary procedure)
90839 Psychotherapy for crisis; first 60 minutes
90840 Psychotherapy for crisis; each additional 30 minutes (List
separately in addition to code for primary service)
90845 Psychoanalysis
90846 Family psychotherapy (without the patient present), 50 minutes
90847 Family psychotherapy (conjoint psychotherapy)(with patient
present), 50 minutes
90863 Pharmacologic management, including prescription and review of
medication, when performed with psychotherapy services (List
separately in addition to the code for primary procedure)
90951 End-stage renal disease (ESRD) related services monthly, for
patients younger than 2 years of age to include monitoring for the
adequacy of nutrition, assessment of growth and development, and
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counseling of parents; with 4 or more face-to-face visits by a
physician or other qualified health care professional per month
90952 End-stage renal disease (ESRD) related services monthly, for
patients younger than 2 years of age to include monitoring for the
adequacy of nutrition, assessment of growth and development, and
counseling of parents; with 2-3 face-to-face visits by a physician or
other qualified health care professional per month
90953 End-stage renal disease (ESRD) related services monthly, for
patients younger than 2 years of age to include monitoring for the
adequacy of nutrition, assessment of growth and development, and
counseling of parents; with 1 face-to-face visit by a physician or
other qualified health care professional per month
90954 End-stage renal disease (ESRD) related services monthly, for
patients 2-11 years of age to include monitoring for the adequacy
of nutrition, assessment of growth and development, and
counseling of parents; with 4 or more face-to-face visits by a
physician or other qualified health care professional per month
90955 End-stage renal disease (ESRD) related services monthly, for
patients 2-11 years of age to include monitoring for the adequacy
of nutrition, assessment of growth and development, and
counseling of parents; with 2-3 face-to-face visits by a physician or
other qualified health care professional per month
90956 End-stage renal disease (ESRD) related services monthly, for
patients 2-11 years of age to include monitoring for the adequacy
of nutrition, assessment of growth and development, and
counseling of parents; with 1 face-to-face visit by a physician or
other qualified health care professional per month
90957 End-stage renal disease (ESRD) related services monthly, for
patients 12-19 years of age to include monitoring for the adequacy
of nutrition, assessment of growth and development, and
counseling of parents; with 4 or more face-to-face visits by a
physician or other qualified health care professional per month
90958 End-stage renal disease (ESRD) related services monthly, for
patients 12-19 years of age to include monitoring for the adequacy
of nutrition, assessment of growth and development, and
counseling of parents; with 2-3 face-to-face visits by a physician or
other qualified health care professional per month
90959 End-stage renal disease (ESRD) related services monthly, for
patients 12-19 years of age to include monitoring for the adequacy
of nutrition, assessment of growth and development, and
counseling of parents; with 1 face-to-face visit by a physician or
other qualified health care professional per month
90960 End-stage renal disease (ESRD) related services monthly, for
patients 20 years of age and older; with 4 or more face-to-face
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visits by a physician or other qualified health care professional per
month
90961 End-stage renal disease (ESRD) related services monthly, for
patients 20 years of age and older; with 2-3 face-to-face visits by a
physician or other qualified health care professional per month
90962 End-stage renal disease (ESRD) related services monthly, for
patients 20 years of age and older; with 1 face-to-face visit by a
physician or other qualified health care professional per month
90963 End-stage renal disease (ESRD) related services for home dialysis
per full month, for patients younger than 2 years of age to include
monitoring for the adequacy of nutrition, assessment of growth and
development, and counseling of parents
90964 End-stage renal disease (ESRD) related services for home dialysis
per full month, for patients 2-11 years of age to include monitoring
for the adequacy of nutrition, assessment of growth and
development, and counseling of parents
90965 End-stage renal disease (ESRD) related services for home dialysis
per full month, for patients 12-19 years of age to include
monitoring for the adequacy of nutrition, assessment of growth and
development, and counseling of parents
90966 End-stage renal disease (ESRD) related services for home dialysis
per full month, for patients 20 years of age and older
90967 End-stage renal disease (ESRD) related services for dialysis less
than a full month of service, per day; for patients younger than 2
years of age
90968 End-stage renal disease (ESRD) related services for dialysis less
than a full month of service, per day; for patients 2-11 years of age
90969 End-stage renal disease (ESRD) related services for dialysis less
than a full month of service, per day; for patients 12-19 years of
age
90970 End-stage renal disease (ESRD) related services for dialysis less
than a full month of service, per day; for patients 20 years of age
and older
92227 Remote imaging for detection of retinal disease (e.g., retinopathy
in a patient with diabetes) with analysis and report under physician
supervision, unilateral or bilateral
92228 Remote imaging for monitoring and management of active retinal
disease (e.g., diabetic retinopathy) with physician review,
interpretation and report, unilateral or bilateral
93228 External mobile cardiovascular telemetry with
electrocardiographic recording, concurrent computerized real time
data analysis and greater than 24 hours of accessible ECG data
storage (retrievable with query) with ECG triggered and patient
selected events transmitter to a remote attended surveillance center
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Proprietary and Confidential Information of UPMC Health Plan TOP © 2020 UPMC All Rights Reserved
for up to 30 days; review and interpretation with report by a
physician or other qualified health care professional
93229 External mobile cardiovascular telemetry with
electrocardiographic recording, concurrent computerized real time
data analysis and greater than 24 hours of accessible ECG data
storage (retrievable with query) with ECG triggered and patient
selected events transmitter to a remote attended surveillance center
for up to 30 days; technical support for connection and patient
instructions for use, attended surveillance, analysis and
transmission of daily and emergent data reports as prescribed by a
physician or other qualified health care professional
93268 External patient and, when performed, auto activated
electrocardiographic rhythm derived event recording with
symptom-related memory loop with remote download capability
up to 30 days, 24-hour attended monitoring; includes transmission,
review and interpretation by a physician or other qualified health
care professional
93270 External patient and, when performed, auto activated
electrocardiographic rhythm derived event recording with
symptom-related memory loop with remote download capability
up to 30 days, 24-hour attended monitoring; recording (includes
connection, recording, and disconnection)
93271 External patient and, when performed, auto activated
electrocardiographic rhythm derived event recording with
symptom-related memory loop with remote download capability
up to 30 days, 24-hour attended monitoring; transmission and
analysis
93272 External patient and, when performed, auto activated
electrocardiographic rhythm derived event recording with
symptom-related memory loop with remote download capability
up to 30 days, 24-hour attended monitoring; review and
interpretation by a physician or other qualified health care
professional
93298 Interrogation device evaluation(s), (remote) up to 30 days;
subcutaneous cardiac rhythm monitor system, including analysis of
recorded heart rhythm data, analysis, review(s) and report(s) by a
physician or other qualified health care professional
96040 Medical genetics and genetic counseling services, each 30 minutes
face-to-face with patient/family
96116 Neurobehavioral status examination (clinical assessment of
thinking, reasoning and judgement, [e.g., acquired knowledge,
attention, language, memory, planning and problem solving, and
visual spatial abilities]), by physician or other qualified health care
professional, both face-to-face time with the patient and time
interpreting test results and preparing the report; first hour
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96121 Neurobehavioral status examination (clinical assessment of
thinking, reasoning and judgement, [e.g., acquired knowledge,
attention, language, memory, planning and problem solving, and
visual spatial abilities]), by physician or other qualified health care
professional, both face-to-face time with the patient and time
interpreting test results and preparing the report; each additional
hour (List separately in addition to code for primary procedure)
96156 Health behavior assessment, or re-assessment (i.e. health-focused
clinical interview, behavioral observations, clinical decision
making)
96158 Health behavior intervention, individual, face-to-face; initial 30
minutes
96159 Health behavior intervention, individual, face-to-face; each
additional 15 minutes (List separately in addition to code for
primary service)
96160 Administration of patient-focused health risk assessment
instrument (e.g., health hazard appraisal) with scoring and
documentation, per standardized instrument
96161 Administration of caregiver-focused health risk assessment
instrument (e.g., depression inventory) for the benefit of the
patient, with scoring and documentation, per standardized
instrument
96164 Health behavior intervention, group (2 or more patients), face-to-
face; initial 30 minutes
96165 Health behavior intervention, group (2 or more patients), face-to-
face; each additional 15 minutes (List separately in addition to
code for primary service)
96167 Health behavior intervention, family (with the patient present),
face-to-face; initial 30 minutes
96168 Health behavior intervention, family (with the patient present),
face-to-face; each additional 15 minutes (List separately in
addition to code for primary service)
96170 Health behavior intervention, family (without the patient present),
face-to-face; initial 30 minutes
96171 Health behavior intervention, family (without the patient present),
face-to-face; each additional 15 minutes (List separately in
addition to code for primary service)
97802 Medical nutrition therapy; initial assessment and intervention,
individual, face-to-face with the patient, each 15 minutes
97803 Medical nutrition therapy; re-assessment and intervention,
individual, face-to-face with the patient, each 15 minutes
97804 Medical nutrition therapy; group (2 or more individual(s)), each 30
minutes
98960 Education and training for patient self-management by a qualified,
nonphysician health care professional using a standardized
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curriculum, face-to-face with the patient (could include
caregiver/family) each 30 minutes; individual patient
98961 Education and training for patient self-management by a qualified,
nonphysician health care professional using a standardized
curriculum, face-to-face with the patient (could include
caregiver/family) each 30 minutes; 2-4 patients
98962 Education and training for patient self-management by a qualified,
nonphysician health care professional using a standardized
curriculum, face-to-face with the patient (could include
caregiver/family) each 30 minutes; 5-8 patients
99201 Office or other outpatient visit for the evaluation and management
of a new patient, which requires these 3 key components: a
problem focused history; a problem focused examination;
straightforward medical decision making
99202 Office or other outpatient visit for the evaluation and management
of a new patient, which requires these 3 key components: an
expanded problem focused history; an expanded problem focused
examination; straightforward medical decision making
99203 Office or other outpatient visit for the evaluation and management
of a new patient, which requires these 3 key components: a
detailed history; a detailed examination; medical decision making
of low complexity
99204 Office or other outpatient visit for the evaluation and management
of a new patient, which requires these 3 key components: a
comprehensive history; a comprehensive examination; medical
decision making of moderate complexity
99205 Office or other outpatient visit for the evaluation and management
of a new patient, which requires these 3 key components: a
comprehensive history; a comprehensive examination; medical
decision making of high complexity
99211 Office or other outpatient visit for the evaluation and management
of an established patient, that may not require the presence of a
physician or other qualified health care professional. Usually, the
presenting problem(s) are minimal. Typically, 5 minutes are spent
performing or supervising these services.
99212 Office or other outpatient visit for the evaluation and management
of an established patient, which requires at least 2 of these 3
components: a problem focused history; a problem focused
examination; straightforward medical decision making
99213 Office or other outpatient visit for the evaluation and management
of an established patient, which requires at least 2 of these 3
components: an expanded problem focused history; an expanded
problem focused examination; medical decision making of low
complexity
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99214 Office or other outpatient visit for the evaluation and management
of an established patient, which requires at least 2 of these 3
components: a detailed history; a detailed examination; medical
decision making of moderate complexity
99215 Office or other outpatient visit for the evaluation and management
of an established patient, which requires at least 2 of these 3
components: a comprehensive history; a comprehensive
examination; medical decision making of high complexity
99231 Subsequent hospital care, per day, for the evaluation and
management of a patient, which requires at least 2 of these 3
components: a problem focused interval history; a problem focused
examination; medical decision making that is straightforward or of
low complexity
99232 Subsequent hospital care, per day, for the evaluation and
management of a patient, which requires at least 2 of these 3
components: an expanded problem focused interval history; an
expanded problem focused examination; medical decision making
of moderate complexity
99233 Subsequent hospital care, per day, for the evaluation and
management of a patient, which requires at least 2 of these 3
components: a detailed interval history; a detailed examination;
medical decision making of high complexity
99241 Office consultation for a new or established patient, which requires
these 3 key components: a problem focused history; a problem
focused examination; and straightforward medical decision making
99242 Office consultation for a new or established patient, which requires
these 3 key components: an expanded problem focused history; an
expanded problem focused examination; and straightforward
medical decision making
99243 Office consultation for a new or established patient, which requires
these 3 key components: a detailed history; a detailed examination;
and medical decision making of low complexity
99244 Office consultation for a new or established patient, which requires
these 3 key components: a comprehensive history; a
comprehensive examination; and medical decision making of
moderate complexity
99245 Office consultation for a new or established patient, which requires
these 3 key components: a comprehensive history; a
comprehensive examination; and medical decision making of high
complexity
99251 Inpatient consultation for a new or established patient, which
requires these 3 key components: a problem focused history; a
problem focused examination; and straightforward medical
decision making
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99252 Inpatient consultation for a new or established patient, which
requires these 3 key components: an expanded problem focused
history; an expanded problem focused examination; and
straightforward medical decision making
99253 Inpatient consultation for a new or established patient, which
requires these 3 key components: a detailed history; a detailed
examination; and medical decision making of low complexity
99254 Inpatient consultation for a new or established patient, which
requires these 3 key components: a comprehensive history; a
comprehensive examination; and medical decision making of
moderate complexity
99255 Inpatient consultation for a new or established patient, which
requires these 3 key components: a comprehensive history; a
comprehensive examination; and medical decision making of high
complexity
99307 Subsequent nursing facility care, per day, for the evaluation and
management of a patient, which requires at least 2 of these 3 key
components: a problem focused interval history; a problem focused
examination; straightforward medical decision making
99308 Subsequent nursing facility care, per day, for the evaluation and
management of a patient, which requires at least 2 of these 3 key
components: an expanded problem focused interval history; an
expanded problem focused examination; medical decision making
of low complexity
99309 Subsequent nursing facility care, per day, for the evaluation and
management of a patient, which requires at least 2 of these 3 key
components: a detailed interval history; a detailed examination;
medical decision making of moderate complexity
99310 Subsequent nursing facility care, per day, for the evaluation and
management of a patient, which requires at least 2 of these 3 key
components: a comprehensive interval history; a comprehensive
examination; medical decision making of high complexity
99354 Prolonged evaluation and management or psychotherapy service(s)
(beyond the typical service time of the primary procedure) in the
office or other outpatient setting requiring direct patient contact
beyond the usual service; first hour (List separately in addition to
code for office or other outpatient Evaluation and Management or
psychotherapy service)
99355 Prolonged evaluation and management or psychotherapy service(s)
(beyond the typical service time of the primary procedure) in the
office or other outpatient setting requiring direct patient contact
beyond the usual service; each additional 30 minutes (List
separately in addition to code for prolonged service)
99356 Prolonged service in the inpatient or observation setting, requiring
unit/floor time beyond the usual service; first hour (List separately
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in addition to code for inpatient Evaluation and Management
service)
99357 Prolonged service in the inpatient or observation setting, requiring
unit/floor time beyond the usual service; each additional 30
minutes (List separately in addition to code for prolonged service)
99406 Smoking and tobacco use cessation counseling visit; intermediate,
greater than 3 minutes up to 10 minutes
99407 Smoking and tobacco use cessation counseling visit; intensive,
greater than 10 minutes
99408 Alcohol and/or substance (other than tobacco) abuse structured
screening (e.g., AUDIT, DAST), and brief intervention (SBI)
services; 15 to 30 minutes
99409 Alcohol and/or substance (other than tobacco) abuse structured
screening (e.g., AUDIT, DAST), and brief intervention (SBI)
services; greater than 30 minutes
99421 Online digital evaluation and management service, for an
established patient, for up to 7 days, cumulative time during the 7
days; 5-10 minutes
99422 Online digital evaluation and management service, for an
established patient, for up to 7 days, cumulative time during the 7
days; 11-20 minutes
99423 Online digital evaluation and management service, for an
established patient, for up to 7 days, cumulative time during the 7
days; 21 or more minutes
99446 Interprofessional telephone/Internet/electronic health record
assessment and management service provided by a consultative
physician, including a verbal and written report to the patient’s
treating/requesting physician or other qualified health care
professional; 5-10 minutes of medical consultative discussion and
review
99447 Interprofessional telephone/Internet/electronic health record
assessment and management service provided by a consultative
physician, including a verbal and written report to the patient’s
treating/requesting physician or other qualified health care
professional; 11-20 minutes of medical consultative discussion and
review
99448 Interprofessional telephone/Internet/electronic health record
assessment and management service provided by a consultative
physician, including a verbal and written report to the patient’s
treating/requesting physician or other qualified health care
professional; 21-30 minutes of medical consultative discussion and
review
99449 Interprofessional telephone/Internet/electronic health record
assessment and management service provided by a consultative
physician, including a verbal and written report to the patient’s
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treating/requesting physician or other qualified health care
professional; 31 minutes or more of medical consultative
discussion and review
99451 Interprofessional telephone/Internet/electronic health record
assessment and management service provided by a consultative
physician, including a written report to the patient’s
treating/requesting physician or other qualified health care
professional, 5 minutes or more of medical consultative time
99452 Interprofessional telephone/Internet/electronic health record
referral service(s) provided by a treating/requesting physician or
other qualified health care professional, 30 minutes
99453 Remote monitoring of physiologic parameter(s) (e.g., weight blood
pressure, pulse oximetry, respiratory flow rate), initial; set-up and
patient education on use of equipment
99454 Remote monitoring of physiologic parameter(s) (e.g., weight blood
pressure, pulse oximetry, respiratory flow rate), initial; device(s)
supply with daily recording(s) or programmed alert(s)
transmission, each 30 days
99457 Remote physiologic monitoring treatment management services,
clinical staff/physician/ other qualified health care professional
time in a calendar month requiring interactive communication with
the patient/caregiver during the month; first 20 minutes
99458 Remote physiologic monitoring treatment management services,
clinical staff/physician/ other qualified health care professional
time in a calendar month requiring interactive communication with
the patient/caregiver during the month; each additional 20 minutes
(List separately in addition to code for primary procedure)
99473 Self-measured blood pressure using a device validated for clinical
accuracy; patient education/training and device calibration
99474 Self-measured blood pressure using a device validated for clinical
accuracy; separate self-measurements of two readings one minute
apart, twice daily over a 30-day period (minimum of 12 readings),
collection of data reported by the patient and/or caregiver to the
physician or other qualified health care professional, with report of
average systolic and diastolic pressures and subsequent
communication of a treatment plan to the patient
99495 Transitional Care Management Services with the following require
elements: Communication (direct contact, telephone, electronic)
with the patient and/or caregiver within 2 business days of
discharge; medical decision making of at least moderate
complexity during the service period; face-to-face visit, within 14
calendar days of discharge
99496 Transitional Care Management Services with the following require
elements: communication (direct contact, telephone, electronic)
with the patient and/or caregiver within 2 business days of
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discharge; medical decision making of high complexity during the
service period; face-to-face visit, with 7 calendar days of discharge
99497 Advance care planning including the explanation and discussion of
advance directives such as standard forms (with completion of
such forms, when performed), by the physician or other qualified
health care professional; first 30 minutes, face-to-face with the
patient, family member(s), and/or surrogate
99498 Advance care planning including the explanation and discussion of
advance directives such as standard forms (with completion of
such forms, when performed), by the physician or other qualified
health care professional; each additional 30 minutes (List
separately in addition to code for primary procedure)
99499 Unlisted evaluation and management service
Commercial Coding
HCPCS Code: Description
G0108 Diabetes outpatient self-management training services, individual,
per 30 minutes
G0109 Diabetes outpatient self-management training services, group
session (2 or more), per 30 minutes
G0270 Medical nutrition therapy; reassessment and subsequent
intervention(s) following second referral in same year for change
in diagnosis, medical condition or treatment regiment (including
additional hours needed for renal disease), individual, face-to-face
with the patient, each 15 minutes
G0296 Counseling visit to discuss need for lung cancer screening using
low dose CT scan (LDCT) (service is for eligibility determination
and shared decision making)
G0396 Alcohol and/or substance (other than tobacco) abuse structured
assessment (e.g., AUDIT, DAST), and brief intervention 15 to 30
minutes
G0397 Alcohol and/or substance (other than tobacco) abuse structured
assessment (e.g., AUDIT, DAST), and intervention, greater than
30 minutes
G0406 Follow-up inpatient consultation, limited, physicians typically
spend 15 minutes communicating with the patient via telehealth
G0407 Follow-up inpatient consultation, intermediate, physicians
typically spend 25 minutes communicating with the patient via
telehealth
G0408 Follow-up inpatient consultation, complex, physicians typically
spend 35 minutes communicating with the patient via telehealth
G0420 Face-to-face educational services related to the care of chronic
kidney disease; individual, per session, per one hour
G0421 Face-to-face educational services related to the care of chronic
kidney disease; group, per session, per one hour
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G0425 Telehealth consultation, emergency department or initial inpatient,
typically 30 minutes communicating with the patient via telehealth
G0426 Telehealth consultation, emergency department or initial inpatient,
typically 50 minutes communicating with the patient via telehealth
G0427 Telehealth consultation, emergency department or initial inpatient,
typically 70 minutes or more communicating with the patient via
telehealth
G0438 Annual wellness visit; includes a personalized prevention plan of
service (PPS), initial visit
G0439 Annual wellness visit, includes a personalized prevention plan of
service (PPS), subsequent visit
G0442 Annual alcohol misuse screening, 15 minutes
G0443 Brief face-to-face behavioral counseling for alcohol misuse, 15
minutes
G0444 Annual depression screening, 15 minutes
G0445 Semiannual high intensity behavioral counseling to prevent STIs,
individual, face-to-face, includes education skills training &
guidance on how to change sexual behavior
G0446 Annual, face-to-face intensive behavioral therapy for
cardiovascular disease, individual, 15 minutes
G0447 Face-to-face behavioral counseling for obesity, 15 minutes
G0459 Inpatient telehealth pharmacologic management, including
prescription, use, and review of medication with no more than
minimal medical psychotherapy
G0506 Comprehensive assessment of and care planning for patients
requiring chronic care management services (list separately in
addition to primary monthly care management service)
G0508 Telehealth consultation, critical care, initial, physicians typically
spend 60 minutes communicating with the patient and providers
via telehealth
G0509 Telehealth consultation, critical care, subsequent, physicians
typically spend 50 minutes communicating with the patient and
providers via telehealth
G0513 Prolonged preventive service(s)(beyond the typical service time of
the primary procedure), in the office or other outpatient setting
requiring direct patient contact beyond the usual service; first 30
minutes (list separately in addition to code for preventive service)
G0514 Prolonged preventive service(s)(beyond the typical service time of
the primary procedure), in the office or other outpatient setting
requiring direct patient contact beyond the usual service; each
additional 30 minutes (list separately in addition to code G0513 for
additional 30 minutes of preventative service)
G2010 Remote evaluation of recorded video and/or images submitted by
an established patient (e.g., store and forward), including
interpretation with follow-up with the patient with 24 business
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hours, not originating from a related E/M service provided within
the previous 7 days nor leading to an E/M service or procedure
within the next 24 hours or soonest available appointment
G2011 Alcohol and/or substance (other than tobacco) abuse structured
assessment (e.g., audit, DAST), and brief intervention, 5-14
minutes
G2012 Brief communication technology-based service, e.g., virtual check-
in, by a physician or other qualified health care professional who
can report evaluation and management services, provided to an
established patient, not originating from a related E/M service
provided within the previous 7 days nor leading to an E/M service
or procedure within the next 24 hours or soonest available
appointment; 5-10 minutes of medical discussion
G2061 Qualified nonphysician health care professional online assessment,
for an established patient, for up to 7 days, cumulative time during
the 7 days; 5-10 minutes
G2062 Qualified nonphysician health care professional online assessment
service, for an established patient, for up to 7 days, cumulative
time during the 7 days; 11-20 minutes
G2063 Qualified nonphysician qualified health care professional
assessment service, for an established patient, for up to 7 days,
cumulative time during the 7 days; 21 or more minutes
G2086 Office-based treatment for opioid use disorder, including
development of the treatment plan, care coordination, individual
therapy and group therapy and counseling; at least 70 minutes in
the first calendar month
G2087 Office-based treatment for opioid use disorder, including care
coordination, individual therapy and group therapy and counseling;
at least 60 minutes in a subsequent calendar month
G2088 Office-based treatment for opioid use disorder, including care
coordination, individual therapy and group therapy and counseling;
each additional 30 minutes beyond the first 120 minutes (list
separately in addition to code for primary procedure)
Q3014 Telehealth originating site facility fee
T1014 Telehealth transmission, per minute, professional services bill
separately
Medical Assistance and CHC Coding
CPT Code: Description
92227 Remote imaging for detection of retinal disease (e.g., retinopathy
in a patient with diabetes) with analysis and report under physician
supervision, unilateral or bilateral
92228 Remote imaging for monitoring and management of active retinal
disease (e.g., diabetic retinopathy) with physician review,
interpretation and report, unilateral or bilateral
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93228 External mobile cardiovascular telemetry with
electrocardiographic recording, concurrent computerized real time
data analysis and greater than 24 hours of accessible ECG data
storage (retrievable with query) with ECG triggered and patient
selected events transmitter to a remote attended surveillance center
for up to 30 days; review and interpretation with report by a
physician or other qualified health care professional
93268 External patient and, when performed, auto activated
electrocardiographic rhythm derived event recording with
symptom-related memory loop with remote download capability
up to 30 days, 24-hour attended monitoring; includes transmission,
review and interpretation by a physician or other qualified health
care professional
93270 External patient and, when performed, auto activated
electrocardiographic rhythm derived event recording with
symptom-related memory loop with remote download capability
up to 30 days, 24-hour attended monitoring; recording (includes
connection, recording, and disconnection)
93271 External patient and, when performed, auto activated
electrocardiographic rhythm derived event recording with
symptom-related memory loop with remote download capability
up to 30 days, 24-hour attended monitoring; transmission and
analysis
93272 External patient and, when performed, auto activated
electrocardiographic rhythm derived event recording with
symptom-related memory loop with remote download capability
up to 30 days, 24-hour attended monitoring; review and
interpretation by a physician or other qualified health care
professional
93298 Interrogation device evaluation(s), (remote) up to 30 days;
subcutaneous cardiac rhythm monitor system, including analysis of
recorded heart rhythm data, analysis, review(s) and report(s) by a
physician or other qualified health care professional
96040 Medical genetics and genetic counseling services, each 30 minutes
face-to-face with patient/family
98960 Education and training for patient self-management by a qualified,
nonphysician health care professional using a standardized
curriculum, face-to-face with the patient (could include
caregiver/family) each 30 minutes; individual patient
99201 Office or other outpatient visit for the evaluation and management
of a new patient, which requires these 3 key components: a
problem focused history; a problem focused examination;
straightforward medical decision making
99202 Office or other outpatient visit for the evaluation and management
of a new patient, which requires these 3 key components: an
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expanded problem focused history; an expanded problem focused
examination; straightforward medical decision making
99203 Office or other outpatient visit for the evaluation and management
of a new patient, which requires these 3 key components: a
detailed history; a detailed examination; medical decision making
of low complexity
99204 Office or other outpatient visit for the evaluation and management
of a new patient, which requires these 3 key components: a
comprehensive history; a comprehensive examination; medical
decision making of moderate complexity
99205 Office or other outpatient visit for the evaluation and management
of a new patient, which requires these 3 key components: a
comprehensive history; a comprehensive examination; medical
decision making of high complexity
99211 Office or other outpatient visit for the evaluation and management
of an established patient, that may not require the presence of a
physician or other qualified health care professional. Usually, the
presenting problem(s) are minimal. Typically, 5 minutes are spent
performing or supervising these services.
99212 Office or other outpatient visit for the evaluation and management
of an established patient, which requires at least 2 of these 3
components: a problem focused history; a problem focused
examination; straightforward medical decision making
99213 Office or other outpatient visit for the evaluation and management
of an established patient, which requires at least 2 of these 3
components: an expanded problem focused history; an expanded
problem focused examination; medical decision making of low
complexity
99214 Office or other outpatient visit for the evaluation and management
of an established patient, which requires at least 2 of these 3
components: a detailed history; a detailed examination; medical
decision making of moderate complexity
99215 Office or other outpatient visit for the evaluation and management
of an established patient, which requires at least 2 of these 3
components: a comprehensive history; a comprehensive
examination; medical decision making of high complexity
99231 Subsequent hospital care, per day, for the evaluation and
management of a patient, which requires at least 2 of these 3
components: a problem focused interval history; a problem focused
examination; medical decision making that is straightforward or of
low complexity
99232 Subsequent hospital care, per day, for the evaluation and
management of a patient, which requires at least 2 of these 3
components: an expanded problem focused interval history; an
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expanded problem focused examination; medical decision making
of moderate complexity
99233 Subsequent hospital care, per day, for the evaluation and
management of a patient, which requires at least 2 of these 3
components: a detailed interval history; a detailed examination;
medical decision making of high complexity
99241 Office consultation for a new or established patient, which requires
these 3 key components: a problem focused history; a problem
focused examination; and straightforward medical decision making
99242 Office consultation for a new or established patient, which requires
these 3 key components: an expanded problem focused history; an
expanded problem focused examination; and straightforward
medical decision making
99243 Office consultation for a new or established patient, which requires
these 3 key components: a detailed history; a detailed examination;
and medical decision making of low complexity
99244 Office consultation for a new or established patient, which requires
these 3 key components: a comprehensive history; a
comprehensive examination; and medical decision making of
moderate complexity
99245 Office consultation for a new or established patient, which requires
these 3 key components: a comprehensive history; a
comprehensive examination; and medical decision making of high
complexity
99251 Inpatient consultation for a new or established patient, which
requires these 3 key components: a problem focused history; a
problem focused examination; and straightforward medical
decision making
99252 Inpatient consultation for a new or established patient, which
requires these 3 key components: an expanded problem focused
history; an expanded problem focused examination; and
straightforward medical decision making
99253 Inpatient consultation for a new or established patient, which
requires these 3 key components: a detailed history; a detailed
examination; and medical decision making of low complexity
99254 Inpatient consultation for a new or established patient, which
requires these 3 key components: a comprehensive history; a
comprehensive examination; and medical decision making of
moderate complexity
99255 Inpatient consultation for a new or established patient, which
requires these 3 key components: a comprehensive history; a
comprehensive examination; and medical decision making of high
complexity
99307 Subsequent nursing facility care, per day, for the evaluation and
management of a patient, which requires at least 2 of these 3 key
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components: a problem focused interval history; a problem focused
examination; straightforward medical decision making
99308 Subsequent nursing facility care, per day, for the evaluation and
management of a patient, which requires at least 2 of these 3 key
components: an expanded problem focused interval history; an
expanded problem focused examination; medical decision making
of low complexity
99309 Subsequent nursing facility care, per day, for the evaluation and
management of a patient, which requires at least 2 of these 3 key
components: a detailed interval history; a detailed examination;
medical decision making of moderate complexity
99310 Subsequent nursing facility care, per day, for the evaluation and
management of a patient, which requires at least 2 of these 3 key
components: a comprehensive interval history; a comprehensive
examination; medical decision making of high complexity
99421 Online digital evaluation and management service, for an
established patient, for up to 7 days, cumulative time during the 7
days; 5-10 minutes
99422 Online digital evaluation and management service, for an
established patient, for up to 7 days, cumulative time during the 7
days; 11-20 minutes
99423 Online digital evaluation and management service, for an
established patient, for up to 7 days, cumulative time during the 7
days; 21 or more minutes
99497 Advance care planning including the explanation and discussion of
advance directives such as standard forms (with completion of
such forms, when performed), by the physician or other qualified
health care professional; first 30 minutes, face-to-face with the
patient, family member(s), and/or surrogate
99498 Advance care planning including the explanation and discussion of
advance directives such as standard forms (with completion of
such forms, when performed), by the physician or other qualified
health care professional; each additional 30 minutes (List
separately in addition to code for primary procedure)
Medical Assistance and CHC Coding
HCPCS Code: Description
Q3014 Telehealth originating site facility fee
Medicare Coding
CPT Code: Description
90785 Interactive complexity (List separately in addition to the code for
primary procedure)
90791 Psychiatric diagnostic evaluation
90792 Psychiatric diagnostic evaluation with medical services
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90832 Psychotherapy, 30 minutes with patient
90833 Psychotherapy, 30 minutes with patient when performed with an
evaluation and management service (List separately in addition to
the code for primary procedure)
90834 Psychotherapy, 45 minutes with patient
90836 Psychotherapy, 45 minutes with patient when performed with an
evaluation and management service (List separately in addition to
the code for primary procedure)
90837 Psychotherapy, 60 minutes with patient
90838 Psychotherapy, 60 minutes with patient when performed with an
evaluation and management service (List separately in addition to
the code for primary procedure)
90839 Psychotherapy for crisis; first 60 minutes
90840 Psychotherapy for crisis; each additional 30 minutes (List
separately in addition to code for primary service)
90845 Psychoanalysis
90951 End-stage renal disease (ESRD) related services monthly, for
patients younger than 2 years of age to include monitoring for the
adequacy of nutrition, assessment of growth and development, and
counseling of parents; with 4 or more face-to-face visits by a
physician or other qualified health care professional per month
90952 End-stage renal disease (ESRD) related services monthly, for
patients younger than 2 years of age to include monitoring for the
adequacy of nutrition, assessment of growth and development, and
counseling of parents; with 2-3 face-to-face visits by a physician or
other qualified health care professional per month
90953 End-stage renal disease (ESRD) related services monthly, for
patients younger than 2 years of age to include monitoring for the
adequacy of nutrition, assessment of growth and development, and
counseling of parents; with 1 face-to-face visit by a physician or
other qualified health care professional per month
90954 End-stage renal disease (ESRD) related services monthly, for
patients 2-11 years of age to include monitoring for the adequacy
of nutrition, assessment of growth and development, and
counseling of parents; with 4 or more face-to-face visits by a
physician or other qualified health care professional per month
90955 End-stage renal disease (ESRD) related services monthly, for
patients 2-11 years of age to include monitoring for the adequacy
of nutrition, assessment of growth and development, and
counseling of parents; with 2-3 face-to-face visits by a physician or
other qualified health care professional per month
90956 End-stage renal disease (ESRD) related services monthly, for
patients 2-11 years of age to include monitoring for the adequacy
of nutrition, assessment of growth and development, and
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counseling of parents; with 1 face-to-face visit by a physician or
other qualified health care professional per month
90957 End-stage renal disease (ESRD) related services monthly, for
patients 12-19 years of age to include monitoring for the adequacy
of nutrition, assessment of growth and development, and
counseling of parents; with 4 or more face-to-face visits by a
physician or other qualified health care professional per month
90958 End-stage renal disease (ESRD) related services monthly, for
patients 12-19 years of age to include monitoring for the adequacy
of nutrition, assessment of growth and development, and
counseling of parents; with 2-3 face-to-face visits by a physician or
other qualified health care professional per month
90959 End-stage renal disease (ESRD) related services monthly, for
patients 12-19 years of age to include monitoring for the adequacy
of nutrition, assessment of growth and development, and
counseling of parents; with 1 face-to-face visit by a physician or
other qualified health care professional per month
90960 End-stage renal disease (ESRD) related services monthly, for
patients 20 years of age and older; with 4 or more face-to-face
visits by a physician or other qualified health care professional per
month
90961 End-stage renal disease (ESRD) related services monthly, for
patients 20 years of age and older; with 2-3 face-to-face visits by a
physician or other qualified health care professional per month
90962 End-stage renal disease (ESRD) related services monthly, for
patients 20 years of age and older; with 1 face-to-face visit by a
physician or other qualified health care professional per month
90963 End-stage renal disease (ESRD) related services for home dialysis
per full month, for patients younger than 2 years of age to include
monitoring for the adequacy of nutrition, assessment of growth and
development, and counseling of parents
90964 End-stage renal disease (ESRD) related services for home dialysis
per full month, for patients 2-11 years of age to include monitoring
for the adequacy of nutrition, assessment of growth and
development, and counseling of parents
90965 End-stage renal disease (ESRD) related services for home dialysis
per full month, for patients 12-19 years of age to include
monitoring for the adequacy of nutrition, assessment of growth and
development, and counseling of parents
90966 End-stage renal disease (ESRD) related services for home dialysis
per full month, for patients 20 years of age and older
90967 End-stage renal disease (ESRD) related services for dialysis less
than a full month of service, per day; for patients younger than 2
years of age
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90968 End-stage renal disease (ESRD) related services for dialysis less
than a full month of service, per day; for patients 2-11 years of age
90969 End-stage renal disease (ESRD) related services for dialysis less
than a full month of service, per day; for patients 12-19 years of
age
90970 End-stage renal disease (ESRD) related services for dialysis less
than a full month of service, per day; for patients 20 years of age
and older
92227 Remote imaging for detection of retinal disease (e.g., retinopathy
in a patient with diabetes) with analysis and report under physician
supervision, unilateral or bilateral
92228 Remote imaging for monitoring and management of active retinal
disease (e.g., diabetic retinopathy) with physician review,
interpretation and report, unilateral or bilateral
93228 External mobile cardiovascular telemetry with
electrocardiographic recording, concurrent computerized real time
data analysis and greater than 24 hours of accessible ECG data
storage (retrievable with query) with ECG triggered and patient
selected events transmitter to a remote attended surveillance center
for up to 30 days; review and interpretation with report by a
physician or other qualified health care professional
93229 External mobile cardiovascular telemetry with
electrocardiographic recording, concurrent computerized real time
data analysis and greater than 24 hours of accessible ECG data
storage (retrievable with query) with ECG triggered and patient
selected events transmitter to a remote attended surveillance center
for up to 30 days; technical support for connection and patient
instructions for use, attended surveillance, analysis and
transmission of daily and emergent data reports as prescribed by a
physician or other qualified health care professional
93268 External patient and, when performed, auto activated
electrocardiographic rhythm derived event recording with
symptom-related memory loop with remote download capability
up to 30 days, 24-hour attended monitoring; includes transmission,
review and interpretation by a physician or other qualified health
care professional
93270 External patient and, when performed, auto activated
electrocardiographic rhythm derived event recording with
symptom-related memory loop with remote download capability
up to 30 days, 24-hour attended monitoring; recording (includes
connection, recording, and disconnection)
93271 External patient and, when performed, auto activated
electrocardiographic rhythm derived event recording with
symptom-related memory loop with remote download capability
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up to 30 days, 24-hour attended monitoring; transmission and
analysis
93272 External patient and, when performed, auto activated
electrocardiographic rhythm derived event recording with
symptom-related memory loop with remote download capability
up to 30 days, 24-hour attended monitoring; review and
interpretation by a physician or other qualified health care
professional
93298 Interrogation device evaluation(s), (remote) up to 30 days;
subcutaneous cardiac rhythm monitor system, including analysis of
recorded heart rhythm data, analysis, review(s) and report(s) by a
physician or other qualified health care professional
96116 Neurobehavioral status examination (clinical assessment of
thinking, reasoning and judgement, [e.g., acquired knowledge,
attention, language, memory, planning and problem solving, and
visual spatial abilities]), by physician or other qualified health care
professional, both face-to-face time with the patient and time
interpreting test results and preparing the report; first hour
96121 Neurobehavioral status examination (clinical assessment of
thinking, reasoning and judgement, [e.g., acquired knowledge,
attention, language, memory, planning and problem solving, and
visual spatial abilities]), by physician or other qualified health care
professional, both face-to-face time with the patient and time
interpreting test results and preparing the report; each additional
hour (List separately in addition to code for primary procedure)
96156 Health behavior assessment, or re-assessment (i.e. health-focused
clinical interview, behavioral observations, clinical decision
making)
96158 Health behavior intervention, individual, face-to-face; initial 30
minutes
96159 Health behavior intervention, individual, face-to-face; each
additional 15 minutes (List separately in addition to code for
primary service)
96160 Administration of patient-focused health risk assessment
instrument (e.g., health hazard appraisal) with scoring and
documentation, per standardized instrument
96161 Administration of caregiver-focused health risk assessment
instrument (e.g., depression inventory) for the benefit of the
patient, with scoring and documentation, per standardized
instrument
96164 Health behavior intervention, group (2 or more patients), face-to-
face; initial 30 minutes
96165 Health behavior intervention, group (2 or more patients), face-to-
face; each additional 15 minutes (List separately in addition to
code for primary service)
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96167 Health behavior intervention, family (with the patient present),
face-to-face; initial 30 minutes
96168 Health behavior intervention, family (with the patient present),
face-to-face; each additional 15 minutes (List separately in
addition to code for primary service)
97802 Medical nutrition therapy; initial assessment and intervention,
individual, face-to-face with the patient, each 15 minutes
97803 Medical nutrition therapy; re-assessment and intervention,
individual, face-to-face with the patient, each 15 minutes
97804 Medical nutrition therapy; group (2 or more individual(s)), each 30
minutes
98960 Education and training for patient self-management by a qualified,
nonphysician health care professional using a standardized
curriculum, face-to-face with the patient (could include
caregiver/family) each 30 minutes; individual patient
99201 Office or other outpatient visit for the evaluation and management
of a new patient, which requires these 3 key components: a
problem focused history; a problem focused examination;
straightforward medical decision making
99202 Office or other outpatient visit for the evaluation and management
of a new patient, which requires these 3 key components: an
expanded problem focused history; an expanded problem focused
examination; straightforward medical decision making
99203 Office or other outpatient visit for the evaluation and management
of a new patient, which requires these 3 key components: a
detailed history; a detailed examination; medical decision making
of low complexity
99204 Office or other outpatient visit for the evaluation and management
of a new patient, which requires these 3 key components: a
comprehensive history; a comprehensive examination; medical
decision making of moderate complexity
99205 Office or other outpatient visit for the evaluation and management
of a new patient, which requires these 3 key components: a
comprehensive history; a comprehensive examination; medical
decision making of high complexity
99211 Office or other outpatient visit for the evaluation and management
of an established patient, that may not require the presence of a
physician or other qualified health care professional. Usually, the
presenting problem(s) are minimal. Typically, 5 minutes are spent
performing or supervising these services.
99212 Office or other outpatient visit for the evaluation and management
of an established patient, which requires at least 2 of these 3
components: a problem focused history; a problem focused
examination; straightforward medical decision making
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99213 Office or other outpatient visit for the evaluation and management
of an established patient, which requires at least 2 of these 3
components: an expanded problem focused history; an expanded
problem focused examination; medical decision making of low
complexity
99214 Office or other outpatient visit for the evaluation and management
of an established patient, which requires at least 2 of these 3
components: a detailed history; a detailed examination; medical
decision making of moderate complexity
99215 Office or other outpatient visit for the evaluation and management
of an established patient, which requires at least 2 of these 3
components: a comprehensive history; a comprehensive
examination; medical decision making of high complexity
99231 Subsequent hospital care, per day, for the evaluation and
management of a patient, which requires at least 2 of these 3
components: a problem focused interval history; a problem focused
examination; medical decision making that is straightforward or of
low complexity
99232 Subsequent hospital care, per day, for the evaluation and
management of a patient, which requires at least 2 of these 3
components: an expanded problem focused interval history; an
expanded problem focused examination; medical decision making
of moderate complexity
99233 Subsequent hospital care, per day, for the evaluation and
management of a patient, which requires at least 2 of these 3
components: a detailed interval history; a detailed examination;
medical decision making of high complexity
99307 Subsequent nursing facility care, per day, for the evaluation and
management of a patient, which requires at least 2 of these 3 key
components: a problem focused interval history; a problem focused
examination; straightforward medical decision making
99308 Subsequent nursing facility care, per day, for the evaluation and
management of a patient, which requires at least 2 of these 3 key
components: an expanded problem focused interval history; an
expanded problem focused examination; medical decision making
of low complexity
99309 Subsequent nursing facility care, per day, for the evaluation and
management of a patient, which requires at least 2 of these 3 key
components: a detailed interval history; a detailed examination;
medical decision making of moderate complexity
99310 Subsequent nursing facility care, per day, for the evaluation and
management of a patient, which requires at least 2 of these 3 key
components: a comprehensive interval history; a comprehensive
examination; medical decision making of high complexity
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99354 Prolonged evaluation and management or psychotherapy service(s)
(beyond the typical service time of the primary procedure) in the
office or other outpatient setting requiring direct patient contact
beyond the usual service; first hour (List separately in addition to
code for office or other outpatient Evaluation and Management or
psychotherapy service)
99355 Prolonged evaluation and management or psychotherapy service(s)
(beyond the typical service time of the primary procedure) in the
office or other outpatient setting requiring direct patient contact
beyond the usual service; each additional 30 minutes (List
separately in addition to code for prolonged service)
99356 Prolonged service in the inpatient or observation setting, requiring
unit/floor time beyond the usual service; first hour (List separately
in addition to code for inpatient Evaluation and Management
service)
99357 Prolonged service in the inpatient or observation setting, requiring
unit/floor time beyond the usual service; each additional 30
minutes (List separately in addition to code for prolonged service)
99406 Smoking and tobacco use cessation counseling visit; intermediate,
greater than 3 minutes up to 10 minutes
99407 Smoking and tobacco use cessation counseling visit; intensive,
greater than 10 minutes
99421 Online digital evaluation and management service, for an
established patient, for up to 7 days, cumulative time during the 7
days; 5-10 minutes
99422 Online digital evaluation and management service, for an
established patient, for up to 7 days, cumulative time during the 7
days; 11-20 minutes
99423 Online digital evaluation and management service, for an
established patient, for up to 7 days, cumulative time during the 7
days; 21 or more minutes
99446 Interprofessional telephone/Internet/electronic health record
assessment and management service provided by a consultative
physician, including a verbal and written report to the patient’s
treating/requesting physician or other qualified health care
professional; 5-10 minutes of medical consultative discussion and
review
99447 Interprofessional telephone/Internet/electronic health record
assessment and management service provided by a consultative
physician, including a verbal and written report to the patient’s
treating/requesting physician or other qualified health care
professional; 11-20 minutes of medical consultative discussion and
review
99448 Interprofessional telephone/Internet/electronic health record
assessment and management service provided by a consultative
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physician, including a verbal and written report to the patient’s
treating/requesting physician or other qualified health care
professional; 21-30 minutes of medical consultative discussion and
review
99449 Interprofessional telephone/Internet/electronic health record
assessment and management service provided by a consultative
physician, including a verbal and written report to the patient’s
treating/requesting physician or other qualified health care
professional; 31 minutes or more of medical consultative
discussion and review
99451 Interprofessional telephone/Internet/electronic health record
assessment and management service provided by a consultative
physician, including a written report to the patient’s
treating/requesting physician or other qualified health care
professional, 5 minutes or more of medical consultative time
99452 Interprofessional telephone/Internet/electronic health record
referral service(s) provided by a treating/requesting physician or
other qualified health care professional, 30 minutes
99453 Remote monitoring of physiologic parameter(s) (e.g., weight blood
pressure, pulse oximetry, respiratory flow rate), initial; set-up and
patient education on use of equipment
99454 Remote monitoring of physiologic parameter(s) (e.g., weight blood
pressure, pulse oximetry, respiratory flow rate), initial; device(s)
supply with daily recording(s) or programmed alert(s)
transmission, each 30 days
99457 Remote physiologic monitoring treatment management services,
clinical staff/physician/ other qualified health care professional
time in a calendar month requiring interactive communication with
the patient/caregiver during the month; first 20 minutes
99458 Remote physiologic monitoring treatment management services,
clinical staff/physician/ other qualified health care professional
time in a calendar month requiring interactive communication with
the patient/caregiver during the month; each additional 20 minutes
(List separately in addition to code for primary procedure)
99473 Self-measured blood pressure using a device validated for clinical
accuracy; patient education/training and device calibration
99474 Self-measured blood pressure using a device validated for clinical
accuracy; separate self-measurements of two readings one minute
apart, twice daily over a 30-day period (minimum of 12 readings),
collection of data reported by the patient and/or caregiver to the
physician or other qualified health care professional, with report of
average systolic and diastolic pressures and subsequent
communication of a treatment plan to the patient
99495 Transitional Care Management Services with the following require
elements: Communication (direct contact, telephone, electronic)
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with the patient and/or caregiver within 2 business days of
discharge; medical decision making of at least moderate
complexity during the service period; face-to-face visit, within 14
calendar days of discharge
99496 Transitional Care Management Services with the following require
elements: communication (direct contact, telephone, electronic)
with the patient and/or caregiver within 2 business days of
discharge; medical decision making of high complexity during the
service period; face-to-face visit, with 7 calendar days of discharge
99497 Advance care planning including the explanation and discussion of
advance directives such as standard forms (with completion of
such forms, when performed), by the physician or other qualified
health care professional; first 30 minutes, face-to-face with the
patient, family member(s), and/or surrogate
99498 Advance care planning including the explanation and discussion of
advance directives such as standard forms (with completion of
such forms, when performed), by the physician or other qualified
health care professional; each additional 30 minutes (List
separately in addition to code for primary procedure)
99499 Unlisted evaluation and management service
Medicare Coding
HCPCS Code: Description
G0108 Diabetes outpatient self-management training services, individual,
per 30 minutes
G0109 Diabetes outpatient self-management training services, group
session (2 or more), per 30 minutes
G0270 Medical nutrition therapy; reassessment and subsequent
intervention(s) following second referral in same year for change
in diagnosis, medical condition or treatment regiment (including
additional hours needed for renal disease), individual, face-to-face
with the patient, each 15 minutes
G0296 Counseling visit to discuss need for lung cancer screening using
low dose CT scan (LDCT) (service is for eligibility determination
and shared decision making)
G0396 Alcohol and/or substance (other than tobacco) abuse structured
assessment (e.g., AUDIT, DAST), and brief intervention 15 to 30
minutes
G0397 Alcohol and/or substance (other than tobacco) abuse structured
assessment (e.g., AUDIT, DAST), and intervention, greater than
30 minutes
G0406 Follow-up inpatient consultation, limited, physicians typically
spend 15 minutes communicating with the patient via telehealth
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G0407 Follow-up inpatient consultation, intermediate, physicians
typically spend 25 minutes communicating with the patient via
telehealth
G0408 Follow-up inpatient consultation, complex, physicians typically
spend 35 minutes communicating with the patient via telehealth
G0420 Face-to-face educational services related to the care of chronic
kidney disease; individual, per session, per one hour
G0421 Face-to-face educational services related to the care of chronic
kidney disease; group, per session, per one hour
G0425 Telehealth consultation, emergency department or initial inpatient,
typically 30 minutes communicating with the patient via telehealth
G0426 Telehealth consultation, emergency department or initial inpatient,
typically 50 minutes communicating with the patient via telehealth
G0427 Telehealth consultation, emergency department or initial inpatient,
typically 70 minutes or more communicating with the patient via
telehealth
G0438 Annual wellness visit; includes a personalized prevention plan of
service (PPS), initial visit
G0439 Annual wellness visit, includes a personalized prevention plan of
service (PPS), subsequent visit
G0442 Annual alcohol misuse screening, 15 minutes
G0443 Brief face-to-face behavioral counseling for alcohol misuse, 15
minutes
G0444 Annual depression screening, 15 minutes
G0445 Semiannual high intensity behavioral counseling to prevent STIs,
individual, face-to-face, includes education skills training &
guidance on how to change sexual behavior
G0446 Annual, face-to-face intensive behavioral therapy for
cardiovascular disease, individual, 15 minutes
G0447 Face-to-face behavioral counseling for obesity, 15 minutes
G0459 Inpatient telehealth pharmacologic management, including
prescription, use, and review of medication with no more than
minimal medical psychotherapy
G0506 Comprehensive assessment of and care planning for patients
requiring chronic care management services (list separately in
addition to primary monthly care management service)
G0508 Telehealth consultation, critical care, initial, physicians typically
spend 60 minutes communicating with the patient and providers
via telehealth
G0509 Telehealth consultation, critical care, subsequent, physicians
typically spend 50 minutes communicating with the patient and
providers via telehealth
G0513 Prolonged preventive service(s)(beyond the typical service time of
the primary procedure), in the office or other outpatient setting
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requiring direct patient contact beyond the usual service; first 30
minutes (list separately in addition to code for preventive service)
G0514 Prolonged preventive service(s)(beyond the typical service time of
the primary procedure), in the office or other outpatient setting
requiring direct patient contact beyond the usual service; each
additional 30 minutes (list separately in addition to code G0513 for
additional 30 minutes of preventative service)
G2010 Remote evaluation of recorded video and/or images submitted by
an established patient (e.g., store and forward), including
interpretation with follow-up with the patient with 24 business
hours, not originating from a related E/M service provided within
the previous 7 days nor leading to an E/M service or procedure
within the next 24 hours or soonest available appointment
G2011 Alcohol and/or substance (other than tobacco) abuse structured
assessment (e.g., audit, DAST), and brief intervention, 5-14
minutes
G2012 Brief communication technology-based service, e.g., virtual check-
in, by a physician or other qualified health care professional who
can report evaluation and management services, provided to an
established patient, not originating from a related E/M service
provided within the previous 7 days nor leading to an E/M service
or procedure within the next 24 hours or soonest available
appointment; 5-10 minutes of medical discussion
G2061 Qualified nonphysician health care professional online assessment,
for an established patient, for up to 7 days, cumulative time during
the 7 days; 5-10 minutes
G2062 Qualified nonphysician health care professional online assessment
service, for an established patient, for up to 7 days, cumulative
time during the 7 days; 11-20 minutes
G2063 Qualified nonphysician qualified health care professional
assessment service, for an established patient, for up to 7 days,
cumulative time during the 7 days; 21 or more minutes
G2086 Office-based treatment for opioid use disorder, including
development of the treatment plan, care coordination, individual
therapy and group therapy and counseling; at least 70 minutes in
the first calendar month
G2087 Office-based treatment for opioid use disorder, including care
coordination, individual therapy and group therapy and counseling;
at least 60 minutes in a subsequent calendar month
G2088 Office-based treatment for opioid use disorder, including care
coordination, individual therapy and group therapy and counseling;
each additional 30 minutes beyond the first 120 minutes (list
separately in addition to code for primary procedure)
Q3014 Telehealth originating site facility fee
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T1014 Telehealth transmission, per minute, professional services bill
separately
G. Quality Assurance & Operational Integrity
Quality Assurance & Operational Integrity monitors policy compliance and/or billing
accuracy at the request of the UPMC Insurance Services Division’s Technology
Assessment Committee or the Benefits Reimbursement Committee.
H. Records Retention
Records Retention for documents, regardless of medium, is provided within the UPMC
Health System Policy for Records Retention, Management and Retirement, and as
indicated in the UPMC Insurance Services Division Policy and Procedure for Records
Retention. Unless otherwise mandated by Federal or State law, or unless required to be maintained
for litigation purposes, any communications recorded pursuant to this Policy are
maintained for a minimum of ten (10) years from the date of recording.
I. References
Please note the following:
• The links and the dates of publication and/or latest revisions for all references below
are current as of the Revision Date of this policy.
• Not all the links are free access. Some of the references may require site registration,
subscription and/or purchase to download the information cited.
Medical Literature/Clinical Information:
N/A
Regulatory/Government Source:
1. U.S. Department of Health & Human Services (HHS). Centers for Medicare and
Medicaid Services (CMS). RIN-0938-AT59. Requirements for Medical Advantage
Plans Offering Additional Telehealth Services (42 CFR §§422.100, 422.135, 422.252,
422.254, and 422.264). 84 FR 15680-15844. April 16, 2019.
https://www.govinfo.gov/content/pkg/FR-2019-04-16/pdf/2019-06822.pdf
2. Pennsylvania Department of Human Services. Medical Assistance Bulletin. MA Bull.
No. 09-12-31, 31-12-31, 33-12-30. Consultations Performed Using Telemedicine.
Issued: May 23, 2012.
http://www.dhs.pa.gov/cs/groups/webcontent/documents/bulletin_admin/d_005993.p
df
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3. U.S. Department of Health & Human Services (HHS). Health Resources & Services
Administration (HRSA). Medicare Telehealth Payment Eligibility Analyzer.
https://data.hrsa.gov/tools/medicare/telehealth
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Disclaimer: UPMC Health Plan medical payment and prior authorization policies do not
constitute medical advice and are not intended to govern or otherwise influence the
practice of medicine. The policies constitute only the reimbursement and coverage
guidelines of UPMC Health Plan and its affiliated managed care entities. Coverage for
services varies for individual members in accordance with the terms and conditions of
applicable Certificates of Coverage, Summary Plan Descriptions, or contracts with
governing regulatory agencies.
UPMC Health Plan reserves the right to review and update the medical payment and prior
authorization guidelines in its sole discretion. Notice of such changes, if necessary, shall
be provided in accordance with the terms and conditions of provider agreements and any
applicable laws or regulations.
These policies are the proprietary information of UPMC Health Plan. Any sale, copying,
or dissemination of said policies is prohibited.